An elderly man with severe chest pressure……

This was sent to me by a medical student:

The patient is an elderly man with no significant past medical history who developed what he describes as chest tightness throughout his anterior precordium, 9/10 in severity, associated with nausea, vomiting, diaphoresis and shortness of breath, lasting for greater than 2 hours, that started while he was lifting firewood. His symptoms did not go away with rest. He presented to his primary care physician's office. An EKG was recorded at 135 minutes after pain onset:
There is no old ECG for comparison.  What do you think?

He was treated with sublingual nitroglycerin and aspirin, which improved his chest discomfort. He was transported by ambulance to the hospital. On initial evaluation in the emergency department he still had pain and had this ECG recorded at 150 minutes (2.5 hours) after pain onset: 
What do you think?  See below.

The med student asked what I thought, and I wrote: "hyperacute T-waves in V4-V6."  Here is the normal relationship between the T-waves and the QRS in V4-V6:
Knowing this is the normal proportion, what do you NOW think about the above 2 ECGs?

It is clear that the T-waves in V4-V6 on the first two ECG are hyperacute.  They are far too large for the QRS.  In addition, if you look closely, you will see that there is more ST elevation on the second ECG.  In fact, on the 1st ECG, V5 had zero ST elevation but has almost 2 mm on the 2nd ECG.

These findings, along with the pretest probability (a 77 year old with persistent substernal chest pressure and diaphoresis!!) mandate at least a stat formal echo, but preferably emergent coronary angiography

Initial cardiac markers were negative. The patient became chest pain-free.  

He was admitted for a "rule out."

A cardiologist evaluated his ECGs:

"In the emergency room an EKG was obtained which showed Q-waves throughout the precordial leads and some reciprocal mild ST elevations but with a distinct J-point and less than 1 mm STE.  I was asked to see the patient and review the ECGs and I felt this represented old anterior MI which had been completed at some point in the remote past."  

I do not fully understand this explanation.

He underwent more ECGs: 200 minutes (2 hours 40 min) after pain onset: 

Complexes 8 and 12 are PVCs. R-waves in leads V4-V6 are much diminished and T-waves are not nearly as tall as they were.
At 270 minutes (4.5 hours) after pain onset, the patient reported a slight increase in pain, and another ECG was recorded:
Now there is ST elevation in V4-V6, the T-waves are still large, and there is poor R-wave progression

The cardiologist wrote this note:

“Pt reported a slight increase in pain. Repeat EKG showed no clear ischemic changes. Old Q waves.”  
At 10.75 hours after the pain onset, the pain was increasing.  Troponin I returned at 7.42 ng/mL.  This ECG was recorded:
Well developed infarction with QS-waves, diminishing T-waves and some terminal T-wave inversion

Another ECG was recorded at 13 hours after pain onset: 
Deepening T-wave Inversion

At 15 hours after the first ECG, the patient was taken for angiogram and had a 100% distal LAD occlusion.  It was opened and stented.

Here is the post cath ECG:
There is deepening T-wave inversion.

Peak troponin I = 29 ng/mL.  Formal echo shortly after the stent placement showed a dyskinetic anterior wall and an EF of 35-40%.

Learning Points

1. T-waves should be proportional to the QRS.  If they are too large, you must suspect hyperacute T-waves and aggressively evaluate the patient with at least a high quality emergent echocardiogram

2. When the ECG is diagnostic, as here, do not wait for troponins to be positive before acting.  Most coronary occlusion has initially negative biomarkers.  Once the troponins are positive, much damage is done.

Covidien’s Fortrex Balloon Catheter Cleared in U.S.

fortex pta Covidiens Fortrex Balloon Catheter Cleared in U.S.

Covidien received FDA clearance for its new Fortrex over-the-wire percutaneous transluminal angioplasty balloon catheter that helps treat blocked arterovenous access sites in dialysis patients . The device, at .035″ (.089 cm) in width, is narrow enough to be used in the peripheral vasculature and can help maintain access during hemodialysis.

Some of the features of the device according to Covidien’s announcement:

  • Optimized balloon delivery: Fortrex™ PTA balloon’s low tip entry profile and robust, flexible shaft design combine to enable tight tracking to the wire and successful navigation in tortuous vessels.
  • Predictable and targeted treatment: The balloon material and design permit shape retention at rated burst pressure, ensuring focused pressure on the lesion for controlled, targeted and predictable treatment.
  • Procedural efficiency: The combination of balloon material and wall thickness enables reliable balloon rewrap and reinsertion along with a top tier deflation time, all of which contribute to the efficiency of the procedure

Press release: Covidien’s Fortrex™ PTA Balloon Receives FDA 510(k) Clearance…

Embrace Watch-Like Device to Help Track Epileptic Seizures (VIDEO)

embrace watch Embrace Watch Like Device to Help Track Epileptic Seizures (VIDEO)

timmy Embrace Watch Like Device to Help Track Epileptic Seizures (VIDEO)Though epileptic seizures are difficult to predict, it can be beneficial to track their occurrence and to be able to let loved ones know when they occur. Parents who have kids that suffer from epilepsy are particularly concerned that seizures will strike when they’re not watching. Now a new wrist-worn watch-like device has been developed that monitors the electric current fluctuations in the skin, among other things, to spot signs of a seizure.

The Embrace device, developed by Empatica (Cambridge, MA) with the help of Rosalind Picard, a professor at the MIT Media Lab, has electrodes that press against the skin, a thermometer to track temperature changes, and accelerometers that detect motion. During a seizure, electrodermal activity goes up, driven by the brain’s electrical hyperactivity. The company has provided some information about how this metric works here. A rapid temperature change and signature shaking can also be picked up by the device. As soon as it thinks a seizure is occurring, the Embrace sends a message to a paired smartphone that will in turn relay it to loved ones.

The team behind the device are now raising funds on Indiegogo to manufacture it and have created this video to show off the Embrace:


Indiegogo campaign: Embrace – A gorgeous watch designed to save lives!

Flashbacks: SMART Belt Detects Seizures, Calls for Help…SAMi Night Time Epilepsy Monitor Helps Track Night Time Seizures…

Students Build Sonar Powered Watch to Help Blind People Get Around

sonar walker Students Build Sonar Powered Watch to Help Blind People Get Around

Though bats are almost blind, they get around just fine thanks to their amazing ability to utilize echolocation. Naturally, it would seem that sonar can help blind people navigate their environment as well, so a team of students at Wake Forest University have developed a wrist-worn device that essentially mimics the bats’ echolocation sense, albeit rather rudimentary compared to the real thing.

The unit has a couple sonar sensors that emit high frequency sound and are able to measure the distance to objects based on the returning echo. This is reinterpreted into vibration that the wearer feels that changes in frequency depending on how close the object in front is.

The team recruited a blind student who normally gets help from a guide dog to get around to test the device, and she was able to successfully recognize closed doors in her way. They next plan to miniaturize the device and to try to make it use less electricity so that it can run on a built-in battery. The current components cost less than $60, which means that this technology may one day turn into a real product.

Wake Forest University: Sonar-assisted human navigation…

Kubtec KUB 250 Neonatal Low Dose Digital X-ray System FDA Approved

kub 250 Kubtec KUB 250 Neonatal Low Dose Digital X ray System FDA Approvedkubtec Kubtec KUB 250 Neonatal Low Dose Digital X ray System FDA Approved

Kubtec (Milford, CT) received FDA approval to introduce its KUB 250 neonatal X-ray system to the U.S. market. The KUB 250 is a portable system intended to stay within the NICU.

It’s a low dosage system that the company claims to produce the highest resolution images available of any competing product. It offers 96 micron pixel size at a radiation up to 40% lower than from other X-rays. The detector is placed within the incubator, on the opposite side of the child, and the X-ray tube is positioned using an articulating arm just outside the glass. The baby doesn’t have to be moved or otherwise troubled during the procedure.

At 24 inches (61 cm) on a side, about the width of the touchscreen monitor on top of the unit, the KUB250 was meant to be small enough to fit next to incubators that often have little extra space around them. There’s a barcode scanner built-in for tracking patients’ images and connectivity to hospital PACS systems for quick uploading of captured X-rays.

Product page: KUB 250…

Press release: Kubtec® Announces FDA Approval of the Highest Resolution Low Dose Portable Digital Radiography System for NICU…

Bronchiolitis, Simplified

There are new guidelines from the American Academy of Pediatrics, just in time for the 2014-15 bronchiolitis season looming on the horizon – as if we don't have enough to worry about with influenza and various West African hemorrhagic fevers.

But, the good news – these guidelines substantially reduce the things you have to remember to do for bronchiolitis.  Specifically, the only evidence-supported intervention you have is:  supportive care.

Ineffective, or of inadequate risk/benefit, treatments:
  • A trial of bronchodilators, such as albuterol or salbutamol.
  • Nebulized epinephrine.
  • Nebulized hypertonic saline, except possibly those requiring hospitalization.
  • Systemic or inhaled corticosteroids.
  • Chest physiotherapy.
… which basically covers everything.

And, not inconsistent with a recent trial regarding the misleading clinical weight of pulse oximetry, the guidelines state it is reasonable not to perform continuous oximetry on infants and children with bronchiolitis, and set 90% as an acceptable oxygen saturation.  Finally, the authors also state routine chest radiography should be avoided, as abnormalities are common in bronchiolitis – thus leading to ineffective, and harmful, antibiotic administration.

Simply put – do no harm!

“Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis”